An epidemic exerts immense political and social pressure for decisive, visible action—more so in the case of a bioattack. Apparent and sometimes genuine conflicts among strategic goals can arise in this charged setting. The most common dilemmas facing past leaders have been balancing disease control imperatives with those of individual liberty, economic stability, and preventing stigma.

Stopping disease that spreads person-to-person while upholding individual freedoms

Case study: Lessons from 2 Smallpox Outbreaks: 1894 Milwaukee, 1947 New York

• Make bioterrorism response plans public before a crisis occurs; a well-informed population is more likely to cooperate with advice for reducing the spread of disease.
• Sketch out the "big picture"; make concrete the fact that personal actions can affect the safety of others—for example, remind people that staying home from work or keeping children out of school when they are ill protects others from getting sick.
• Use disease controls that respect ideals of autonomy, self-determination, and equality—public cooperation limits illness and death; public resistance does not.
• Provide goods and services that help people comply with health orders—for example, set up vaccination clinics in locations accessible to people without cars.
• Restrict civil liberties, if necessary, only in a transparent and equitable way.

Protecting the economy while using disease controls that disrupt commerce

Case studies:
1982, Executives Put Public Safety First
1900, San Francisco Business Leaders Hide Plague

• Be mindful of the goal of long-term financial recovery when controlling disease; do not react based solely on the desire to avert short-term economic loss.
• Recognize public trust as precious "capital" that grows the economy—for example, if people see their health as your top priority, confidence in your efforts to safeguard the economy will follow.
• Account for the less visible and more scattered monetary impacts when making epidemic control decisions (e.g., costs of victims' healthcare; economic toll of stigma).

Restoring social bonds when people feel at the mercy of a mysterious disease or attacker

Case studies:
2001, Post September 11, Some in U.S. Vilify Islam, Others Reach Out
1918 Pandemic Flu Provokes Discrimination and Altruism

• Express empathy for people's fears about getting sick from others; follow up with meaningful medical details that allow people to gauge personal risk accurately.
• Demonstrate compassion toward victims of disease; explain to the community-at-large the social costs of avoiding people out of fear, rather than out of actual danger.
• Provide frequent updates on the criminal investigation; counsel people not to lash out against others who "look like" presumed perpetrators.
• Spotlight community projects aimed at bringing people together across social divisions sensitized by the crisis -- for example, ethnic and religious affiliations in the case of 9/11.
• Direct law enforcement to deal appropriately with hate crimes in the event prevention fails.
• Coordinate volunteers, relief groups, and civic organizations in humanitarian response, with extra focus on assisting the most vulnerable—for example, children, the frail elderly, and disabled people of all ages.

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